This article provides a commentary to Ole Norheim's editorial
entitled "Ethical perspective: Five unacceptable trade-offs on the
path to universal health coverage." It reinforces its message that
an inclusive, participatory process is essential for ethical
decision-making and underlines the crucial importance of good governance
in setting fair priorities in healthcare. Solidarity on both national
and international levels is needed to make progress towards the goal of
universal health coverage (UHC).

In his editorial, (1) Norheim argues that policy decisions relating
to universal health coverage (UHC) are fraught with ethical dilemmas and
involve difficult trade-offs for health policy-makers. The author,
former Chairperson of the World Health Organizations (WHO's)
Consultative Group on Equity and Universal Health Coverage, reminds the
reader that there is an urgent need to frame UHC not only in economic
(financing) terms but to place it within a rigorous ethics framework, as
countries address difficult priority-setting issues in moving towards
UHC.

UHC as a major global health goal is not only a political, but also
an ethical endeavor. The WHO, as the United Nations specialized agency
for international public health, has a unique mandate and longstanding
history of advocating for access to healthcare for all. WHO's 1946
Constitution proclaimed as one of its basic value statements that
"the enjoyment of the highest attainable standard of health is one
of the fundamental rights of every human being without distinction of
race, religion, political belief, economic or social condition."
(2) In 1978, the Declaration of Alma Ata called for primary healthcare
for all people, (3) and WHO's 2008 World Health Report
re-emphasized the commitment to primary healthcare. (4) For the last few
years, motivated by a firm belief in the ethical principle of fair
access to health services for all, the push for UHC has been on top of
WHO's agenda. In fact, in 2013, WHO's Director-General
Margaret Chan stated that "... I regard universal coverage as the
single most powerful concept that public health has to offer.... It
operationalizes the highest ethical principles of public health. It is a
powerful social equalizer and the ultimate expression of fairness."
[1]

Solidarity and Universal Health Coverage

Besides the key ethical concepts of fairness, equity, and benefit
maximization put forward in Norheim's article and the WHO report
"Making fair choices on the path to universal health
coverage," (5) solidarity is an important underlying concept that
can help explain and justify the drive for reaching UHC both at national
as well as international levels.

The Charter of Fundamental Rights of the European Union includes
its provisions for access to healthcare under the section of
"Solidarity": "...Everyone has the right of access to
preventive healthcare and the right to benefit from medical treatment
under the conditions established by national laws and
practices...." (6) Similarly, in other social and cultural
contexts, concepts like neighborliness (eg, in New Zealand (7)) and
Ubuntu (South Africa) are deeply rooted in local values and motivate
mutual action towards a collective goal.

A recent influential report by Prainsack and Buyx, (published by
the British Nuffield Council on Bioethics) on solidarity defines it as
"shared practices reflecting a collective commitment to carry
'costs' (financial, social, emotional or otherwise) to assist
others." (8) Although there is no consensus on a precise definition
of "solidarity," in different forms it is a key underlying
notion of many healthcare and social systems throughout the world and
provides the moral basis for financing mechanisms such as redistribution
and pooling of funds, as well as progressive revenue raising. (9)

If any further proof was needed, the recent epidemic of Ebola virus
disease clearly demonstrated the crucial need for national as well as
international solidarity in support of failing health systems. The
international community witnessed once more that the global response to
epidemics can only be as strong as its weakest link in a country, as
distant as it may seem. It is widely recognized that the limited
capacity of health systems in Guinea, Liberia, and Sierra Leone greatly
facilitated the rapid spread of Ebola. Consequently, major efforts are
now underway to support countries in increasing the resilience of their
respective health systems to future potential threats, (10) which is
fully in line with the WHO Constitution: "The achievement of any
State in the promotion and protection of health is of value to us
all." (2)

However, the international community does not only have
self-interested reasons for working towards strong health systems in all
countries, but also a moral obligation to support lower- and
middle-income countries in the promotion of UHC. (11) Retrospectively,
the Alma Ata Declaration can be seen as essentially a call for global
solidarity: "All countries should cooperate in a spirit of
partnership and service to ensure primary healthcare for all people,
since the attainment of health by people in any one country directly
concerns and benefits every other country." (3)

The Need for Participatory Processes and Good Governance at Country
Level

Norheim clearly lays out the arguments that some policy-options,
while theoretically possible, are in fact unfair and out of bounds from
an ethical perspective, eg, coverage for low-or medium-priority services
before there is near universal coverage for high-priority services. In
addition, his article and the WHO Consultative Group on Equity and UHC
rightly argue that public accountability and participation are crucial
prerequisites for fair priority-setting. People and communities should
not only be put at the center of health services provision, they should
also be engaged in decisions on which services are provided, and with
which level of quality. (12)

Besides the principle of solidarity, good governance at country
level must be regarded as a cornerstone of the movement towards UHC.
While there is no universally accepted definition of "good
governance," and some indeed prefer the term "effective
governance," the general consensus is that the governance function
characterizes a set of processes to distribute responsibility or
accountability among the actors of the health system. (13)

Although fair priority-setting is clearly needed, the fiscal space
also needs to be enlarged, both in absolute terms, but also through the
transparent use of available funds, even if they are deficient. Not only
do many countries still lag behind the internationally recommended
levels of spending on healthcare, but unfortunately, the health sector
often suffers from unethical practices and leakages out of the health
system. The corruption found in the health sector is often a reflection
of more general problems of governance in the public sector. Corruption
and fraud due to lack of effective governance mechanisms have been found
to be among the top ten causes of health system inefficiency, (14) and
an estimated 10%-25% of public spending on health linked to procurement
is lost to corrupt practices. (15) These practices also decrease the
volume and increase the cost of the provided services and have been
shown to have a direct impact on health outcomes. (16)

WHO has developed a number of important initiatives to promote
transparency and good governance, eg, regarding health technology
assessment and managing health workforce migration. In the
pharmaceutical sector, already in 2004 the "Good Governance for
Medicines" programme was started, an initiative which aims at
promoting transparency and ethical practices in the pharmaceutical
sector, and which by now has been embraced by 37 countries. (17) The
concept of good governance is a core element of the implementation of
resolution WHA64. (9) on UHC and the improvement of equitable and
sustainable access to quality assured medicines in countries. (18)
Similar initiatives are needed beyond the pharmaceutical sector for
health systems more generally in order to facilitate accountability to
the public and participation in priority-setting. (19) It is crucial
that countries base their decision-making on the principles of good
governance, accountability, transparency, and fairness. (20) Finally, in
addition to good governance in the health sector, there is a need for
better coordination and governance between related sectors which are key
for tackling the social, economic, environmental, and political
determinants of health ("health in all policies"). (21)

The Need for Ethics Capacity-Building in Countries

Norheim's editorial and the underlying work describe an
essential and innovative theoretical framework and important arguments
at an opportune moment in the history of UHC. While some trade-offs are
clearly unacceptable from an ethical perspective, policy-makers will
still have to make difficult choices in progressing towards UHC. In
practice, in order to facilitate ethical priority-setting on the path to
UHC at country level, policy-makers will need to engage meaningfully
with key stakeholders and communities, and to promote good governance in
their countries. There is a need for professionals who can facilitate
and ensure a fair, deliberative process and its management. Yet many
countries still suffer from a lack of adequate capacity in health
ethics. While most, if not all countries now have ethics committees for
the review of research with human subjects, few will have knowledge in
public health ethics and ethical questions related to resource
allocation and priority-setting. This is why there is a great need for
capacity-building in this area. Where they exist, National Ethics
Committees have potentially an important role to play in the adaptation
of the WHO report on "Fair Choices," as well as in the
training of human resources and the ethical implementation of UHC. Based
on global solidarity, countries should support each other in working
towards reaching the goal of UHC in a fair way.

Acknowledgments

The author thanks the following colleagues for comments on earlier
versions of this manuscript: Maryam Bigdeli, Inke Mathauer, and Johannes
Sommerfeld.

Ethical issues

Not applicable.

Competing interests

The author is a staff member of the WHo. The author alone is
responsible for the views expressed in this article and they do not
necessarily represent the decisions, policy, or views of the WHO.

Author's contribution

AAR is the single author of the paper.

Endnote

[1] Remarks of Dr. Margaret Chan at a WHO/World Bank
ministerial-level meeting on UHC in Geneva on February 18, 2013.
References

(5.) World Health Organization (WHO). Making Fair Choices on the
Path to Universal Health Coverage. Final Report of the WHO Consultative
Group on Equity and Universal Health Coverage. Geneva: WHO; 2014.

(21.) World Health Organization (WHO). Adelaide Statement on Health
in All Policies - moving towards a shared governance for health and
well-being, http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf. Published 2010.

Andreas A. Reis (*)

(*) Correspondence to:

Andreas A. Reis

Email: reisa@who.int

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